197610298-6-3-2026-31-AS-PKHN-DUQ6EZ-20260603204534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610298
Report Date: 06/03/2026
Date Signed: 06/03/2026 08:47:08 PM

Document Has Been Signed on 06/03/2026 08:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LINDLEY RESIDENTIAL CARE		FACILITY NUMBER:	197610298
ADMINISTRATOR/ DIRECTOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	18124 VINTAGE STREET		TELEPHONE:	(818) 983-2224
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 2	DATE:	06/03/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:26 AM
MET WITH:	Larisa Bobakova - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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On 6/3/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by Staff, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. LPA Khurshudyan reviewed the required postings on a wall throughout the facility.

The inspection tool was used to complete today's visit.

At 10:00am LPA with the help of the Staff, began a physical plant tour of the facility and the following was observed: This is a single-story building with three (3) bedrooms, three (3) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (6) Ambulatory Residents, No Dementia Care, and Hospice waiver for four (4) residents. There are three (3) licensed RCFEs in the property.

Kitchen: LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food, all properly stored and labeled. Knives and other sharp items are secured in a locked box placed on the kitchen cabinet, that remains under staff supervision. An emergency supply of food and water was stored inside the pantry located in the hallway next to the laundry closet. LPA observed one fully charged fire extinguisher in the kitchen area, with a service date of 1/7/2026. A weekly menu was also posted and available for review.

Common Areas: The common areas include the living and dining rooms. LPA observed these areas to be clean, well-organized, and free of clutter. Furniture appeared relatively new and in good repair, with seating capacity appropriate for the number of residents. Walls, floors, windows, screens, and blinds were clean and in good condition.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LINDLEY RESIDENTIAL CARE	FACILITY NUMBER: 197610298
	VISIT DATE: 06/03/2026

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At 11:20 AM, LPA measured the room temperature at 72 degrees Fahrenheit. A hallway linen closet contained an adequate supply of fresh linens ready for use. No obstructions or tripping hazards were observed throughout the facility.

A television and a variety of activities, including games, board games, and art supplies, were available for client use.

Bedrooms: The facility has three bedrooms; all rooms are for residents’ use only. LPA observed bedrooms to be properly furnished with beds, linens, nightstands, chairs, dressers, closets, and adequate lighting. All rooms were clean, organized, and in good condition.

Bathrooms: The facility has three (3) bathrooms. Each bathroom was stocked with hand soap, paper towels, toilet paper, and trash bins with lids. At approximately 11:45 a.m., hot water temperatures were measured at 108.2 degrees Fahrenheit. Required signage was posted, and non-skid mats were placed in all shower areas.

Smoke and Carbon Monoxide Detectors: At 2:05 p.m., the Licensee tested all smoke and carbon monoxide detectors. LPA observed them to be in proper working order.

Garage: The garage is currently being used as storage. The door/sliding door accessing the garage is always locked and under supervision.

Laundry Room: A functioning washer and dryer are located next to the pantry. Disinfectants, laundry detergents, and hygiene supplies were stored securely in a locked cabinet and were inaccessible to clients.

Backyard: LPA observed a spacious, fenced backyard with appropriate outdoor furniture and a shaded area for clients to sit and enjoy the outdoors. LPA discussed the importance of maintaining adequate care and supervision to meet client needs. Exit doors were unobstructed and unlocked. The facility does not have a swimming pool or any other body of water.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LINDLEY RESIDENTIAL CARE	FACILITY NUMBER: 197610298
	VISIT DATE: 06/03/2026

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Staff/Client File review: Facility records are stored inside locked cabinets located in the living room. From 11:45 a.m. to 1:50 p.m., LPA reviewed six (6) staff files and two (2) out of two (2) residents files. All records were complete, current, and well-organized.

Medications: At approximately 12:55 p.m., LPA reviewed the Centrally Stored Medication and Destruction Records and found documentation to be generally complete, however, two medications had extra pills with no documentation. The facility does not maintain Medication Administration Records (MARs). Centrally stored medications were observed secured inside a locked commercial cabinet, inaccessible to clients. The first-aid kit was fully stocked and included an up-to-date manual. All PRN medications had current physician orders. Potentially dangerous items were stored securely and kept inaccessible to clients. The facility operates with two shifts, with one staff member assigned per shift. The administrator is on call and visits the facility every day.

An emergency exit plan/sketch is posted on the wall along with other posting requirements.

Both residents were present during the visit; LPA conducted interviews with the residents and 3 staff during the visit.

LPA collected LIC500, LIC9020, copy of Certificate of Liability Insurance, and copy of Administrator Certificate.

Property Liability insurance Exp date is 1/3/2027.

The Administrator's certificate - Exp date is 1/28/27.

LPA informed the Administrator/ Licensee to update LIC610E Emergency Disaster Form and submit the updated form to the department.

A deficiency issued during today's visit, see LIC809-D

Exit interview conducted. Copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/03/2026 08:47 PM - It Cannot Be Edited

Created By: Perchui Khurshudyan On 06/03/2026 at 03:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LINDLEY RESIDENTIAL CARE	FACILITY NUMBER: 197610298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication{....} (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above. LPA oberved extra medication pills inside the medication bottle without any documentation, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	Administrator agreed to conduct Vendored training on Medication for all staff including the Administrator. Submit schedule of the vendored training, include the vendor’ s name, phone number and date of the training. Once training is complete. Staff sign-in sheet with (time, date and subject) and training materials are to be submitted to the department by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:

	Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026

LIC809 (FAS) - (06/04)

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